Registered Nurse (RN) – Utilization Review
The Utilization Review Registered Nurse (RN) is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services and treatment plans. The RN ensures that patients receive quality care while maintaining compliance with payer requirements and hospital policies.
Key Responsibilities:
Review patient medical records for medical necessity and appropriate level of care.
Collaborate with physicians, case managers, and insurance representatives.
Ensure documentation meets regulatory and payer standards.
Perform concurrent, retrospective, and pre-admission reviews.
Identify opportunities for process improvement in care delivery.
Communicate clinical findings effectively to support authorization and reimbursement.
Maintain accurate records and comply with HIPAA standards.
Qualifications:
Active and unrestricted RN license.
Minimum 2 years of clinical nursing experience (critical care, med-surg, or case management preferred).
Experience in utilization review or case management.
Strong knowledge of InterQual or MCG guidelines.
Excellent communication, analytical, and documentation skills.
Work Environment:
Typically hybrid or remote options available.
May work in hospital, insurance company, or managed care setting.
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